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The HHS and DoJ initiatives to fight and prevent healthcare fraud cases resulted in more money being returned to the government or individuals in 2016, OIG found.

January 23, 2017 - Through healthcare fraud cases and settlements in 2016, Department of Health and Human Services (HHS) and Department of Justice (DoJ) initiatives returned over $3.3 billion to the federal government and individuals, including $1.7 billion to Medicare Trust Funds, the Office of the Inspector General (OIG) recently reported.

The 2016 healthcare fraud judgements and settlements also resulted in $235.2 million of federal Medicaid money being returned to the government.

Compared to 2015 results, the Healthcare Fraud and Abuse Control Program recouped $900 million more in 2016 from healthcare fraud investigations and settlements.

Dig Deeper

OIG noted that collaborative efforts by the federal departments through the Healthcare Fraud and Abuse Control Program helped to return more improper claims reimbursements and healthcare payments. The program has returned about $31 billion to the Medicare Trust Funds since 1997.

Over the past seven years, though, the program, though, has seen more funds being returned from healthcare fraud schemes. Since 2009, the program returned over $17.9 billion to the federal government and individuals.

Notably, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) program launched in 2009. OIG pointed out that the HEAT program also went through several data sharing and healthcare prevention program improvements in the last year.

“DoJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud and abuse and increase efficiency in investigating and prosecuting complex healthcare fraud cases,” wrote the OIG. “This expanded data sharing enables the DoJ and HHS to efficiently identify and target the worst actors in the system.”

Healthcare fraud prevention programs sponsored by the federal departments also helped to reduce improper claims reimbursements and healthcare payments. The programs included CMS compliance training for providers, US Attorney Office meetings with the public and private healthcare sector, and HHS educational sessions for patient awareness.

The DoJ and HHS partnership also made news in July 2016 after the DoJ announced the largest healthcare fraud takedown in the federal department’s history. Both departments worked together to charge 301 individuals, including 61 physicians and licensed medical professionals, with reportedly participating in healthcare fraud schemes.

The healthcare fraud schemes totaled approximately $900 million in false medical billing.

Additionally, OIG found that the DoJ investigated slightly less healthcare fraud schemes this year, but still returned more funds to the federal government and Medicare.

DoJ opened 975 new healthcare fraud investigations in 2016, a little under ten cases less than last year’s 983 new healthcare fraud investigations. The federal department also opened 930 new civil healthcare fraud investigations.

Out of the total investigations, federal prosecutors filed criminal charges in 480 cases with 802 defendants.

In terms of convictions, DoJ sentenced 658 defendants for healthcare fraud and related crimes in 2016. The number of convictions is up from 613 defendants in 2015.

The Federal Bureau of Investigation, an arm of the DoJ, also helped to prevent and stop healthcare fraud schemes in 2016. The group disrupted over 555 criminal fraud organizations and broke up criminal hierarchies for over 128 healthcare fraud criminal enterprises.

With the DoJ focusing on general healthcare fraud schemes, OIG, the HHS watchdog, followed Medicaid and Medicare fraud cases. In 2016, OIG brought 765 criminal actions against individuals or entities who were involved in Medicaid or Medicare fraud schemes or related crimes.

The federal watchdog also gave out 690 civil actions in 2016, including false claims and unjust-enrichment lawsuits, civil monetary penalties settlements, and administrative recoveries associated with provider self-disclosures.

Last year, OIG investigations led to 800 criminal actions against Medicaid and Medicare fraud perpetrators and 667 civil actions.

Resulting from Medicaid and Medicare fraud investigations, some providers and other healthcare entities were no longer included in federal healthcare programs. In 2016, OIG excluded 3,635 individuals and entities from participating in Medicaid, Medicare, and other federal healthcare programs.

Out of the total exclusions, most cases (1,448 exclusions) stemmed from licensure revocations, followed by Medicaid and Medicare fraud-related convictions (1,362 exclusions), patient abuse and neglect issues (299 exclusions), and other healthcare program fraud-related convictions (262 exclusions).

Despite working to prevent and fight healthcare fraud, OIG found that the DoJ, FBI, HHS, and OIG faced less funding in 2016. Sequestration of Healthcare Fraud and Abuse Control program funds amounted to $20.6 million in 2016, totaling $94.8 million sequestered over the last four years.

By adding funds sequestered from the FBI and the 2013 discretionary Healthcare Fraud and Abuse Control program sequester, the federal departments and their subsidiaries have lost about $131.3 million for healthcare fraud activities in the past four years.